title: Changing practice as a quality indicator for primary care: analysis of data on voluntary disenrollment from the English GP Patient Survey.
abstract: BACKGROUND
  Changing family practice (voluntary disenrollment) without changing address may indicate dissatisfaction with care. We investigate the potential to use voluntary disenrollment as a quality indicator for primary care.
  
  
  METHODS
  Data from the English national GP Patient Survey (2,169,718 respondents), the number of voluntary disenrollments without change of address, data relating to practice characteristics (ethnicity, deprivation, gender of patients, practice size and practice density) and doctor characteristics were obtained for all family practices in England (n = 8450). Poisson regression analyses examined associations between rates of voluntary disenrollment, patient experience, and practice and doctor characteristics.
  
  
  RESULTS
  Mean and median rates of annual voluntary disenrollment were 11.2 and 7.3 per 1000 patients respectively. Strongest associations with high rates of disenrollment were low practice scores for doctor-patient communication and confidence and trust in the doctor (rate ratios 4.63 and 4.85). In a fully adjusted model, overall satisfaction encompassed other measures of patient experience (rate ratio 3.46). Patients were more likely to move from small practices (single-handed doctors had 2.75 times the disenrollment rate of practices with 6-9 doctors) and where there were other local practices. After allowing for these, substantial unexplained variation remained in practice rates of voluntary disenrollment.
  
  
  CONCLUSIONS
  Family practices with low levels of patient satisfaction, especially for doctor patient communication, are more likely to experience high rates of disenrollment. However substantial variation in disenrollment rates remains among practices with similar levels of patient satisfaction, limiting the utility of voluntary disenrollment as a performance indicator for primary care in England.
authors.affiliation: Cambridge Centre for Health Services Research, Primary Care Unit, Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK.
authors.forename: Shobhana
authors.initials: S
authors.lastname: Nagraj
authors.forename: Gary
authors.initials: G
authors.lastname: Abel
authors.forename: Charlotte
authors.initials: C
authors.lastname: Paddison
authors.forename: Rupert
authors.initials: R
authors.lastname: Payne
authors.forename: Marc
authors.initials: M
authors.lastname: Elliott
authors.forename: John
authors.initials: J
authors.lastname: Campbell
authors.forename: Martin
authors.initials: M
authors.lastname: Roland
mesh_terms: D003625:Data Collection; D004739:England; D005194:Family Practice / Q000592:standards* / Q000706:statistics & numerical data; D006306:Health Surveys; D006801:Humans; D017060:Patient Satisfaction / Q000706:statistics & numerical data*; D010817:Physician-Patient Relations; D011320:Primary Health Care / Q000458:organization & administration / Q000592:standards* / Q000706:statistics & numerical data; D019984:Quality Indicators, Health Care; D020379:Risk Adjustment; D012959:Socioeconomic Factors; D006113:United Kingdom